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Monday, December 6, 2010

How to solve the problems with Alberta Health care in 1 step

the Problem:

Shackleton's Antarctic Journey
Does one plug the leaks on a sinking ship or train the sailors to better accept their fate?
Someone may think that we aren't sinking as we are still floating, others argue that as this isn't a dog sleigh there should be some fixes to the ship, others argue that we should wait till spring and then decide if we are sinking. 
Some may say that since ice is water that the argument should be a philosophical one, other's may argue if its even a ship at all.
Or does one ask as the Alberta health board for flow meters to ensure that the sink rate is within acceptable parameters, historically accurate to other shipwrecks of the past.   
One should see if its the fault of the trees that were used in the construction of the ship as they could have been exposed to disease while a sapling and as such their use as a portion of the ship should be explored, the architects of the current ship should be looked at and assessed blame. 
The ice shouldn't be looked at as the reason it is the more likely fault of incorrect maps, map reading skills, possibly coal burning in factories in England causing a dip in world temperatures which create the little Ice age.
 As well as the potential that its the crews fault for doing tasks as written down within their job performance skill sets and thus we need to better look at their job skill performance outcomes over the next quarter.
We at least can agree that Health Care in Alberta is in need of a fix that can outlive the next rough patch.
How can that be done?
Tax higher?
Bigger oil and gas revenues?
Bigger business taxes?
Demand more from the feds?
2009 –10 Expense by Ministry $36.4 billion
  1. Advanced Education and Technology                8.6%
  2. Health and Wellness                                           35.6%
  3. Education                                                           16.9%
  4. Seniors and Community Supports                      5.4%
  5. Children and Youth Services                              3.1%
  6. Agriculture and Rural Development                   3.1%
  7. Transportation                                                     6.1%
  8. Employment and Immigration                             2.8%
  9. Debt servicing costs                                             0.6%
  10. Other                                                                  17.8%
Alberta Health and Wellness spending is budgeted at $12.9 billion. 
Which if Alberta Health and Wellness were a country it would rate at 72 in the world out of 230 countries, Alberta ranks as a population figure at about 126. 
This includes:
  1. $7.7 billion in operating funding to Alberta Health Services for the delivery of health services across the province, which is a $550 million, or almost an eight per cent, increase from 2008-09 (excluding one-time assistance).
  2. $238 million in infrastructure support for capital projects in addition to approximately $1.5 billion in cash capital reserves already with Alberta Health Services. Support for capital projects increases to over $1 billion in 2010-11 and $1.2 billion in 2011-12.
the Answer:
Moving all infrastructure (number 2 above) to a Ministry of Infrastructure which would then base its spending decisions on political issues (election issues) and as to what is required to maintain and expand the existing facilities.  The reason for the move would be that in these times of high cost of construction and maintenance times we lose focus on some of the important matters of the day.  
"To provide a patient-focused, quality health system that is accessible and sustainable for all Albertans."
Mission statement of Alberta Health Care
The goal should be to make Albertans live longer happier lives.
(Alberta ranks as 30th in the World Health Report....The World Health Organization's ranking 
of the world's health systems  2000, and the WHO no longer produces such a ranking table, 
because of the complexity of the task.)
As an example:
The savings to Alberta Health care in the 2010 - 11 budget is 800 million (capital building projects in number 2. above). and if that 800 million is used to bring in experienced and well educated staff you will suddenly have a content public and a content health care workers.  This "savings" is then directed at hiring and creating a staff that has good morale, equipment to do the job and the most important factor which is job security.  Construction funds come from the 200 million a year for four years which is either borrowed (to get to the required 800 million) from banks, institutions or the Heritage Fund and payed in full by the end of four years.
Building are but one part of this process but so is the staff and the management that is needed to run these facilities.   The new South Calgary Hospital, The Calgary Children's Hospital,  Mazankowski Alberta Health Institute, ER expansion at University of Alberta, the Lois Hole Centre for Women's Health (at the Robbins Centre) Royal Alex, Edmonton Clinic (the Mayo Clinic of the North) the list goes on. These are but examples of what the Government and the people have made as priorities and what have been built as a result with more construction to come including long term care facilities in small communities and in the North.

Moving all hospital, long term care facilities, provincial health offices to the Infrastructure Ministry they then can be looped together.  Each community deserves and requires infrastructure based on community need and future growth/ loss.  This ministry or sub group of all ministries can then assess the need on all community factors. 

The problem is that the savings the Klien government actualized in the 1990's through staff, wages, programs and building cuts are now being eaten up by these massive projects that have a very long life term and which in many ways should not be in the budgets of Alberta Health and Wellness and Alberta Health Care.

Royal Alexander hospital with expansion in The Lois Hole Hospital for Women (190 million), The Cardiac centre Medical Assessment Unit, the Joint Replacement Centre (60 million)
South Calgary Clinic/ hospital (1.2 billion)
Edmonton North clinic (900 million)

Alberta Children's Hospital Calgary,
Cost 253 million
What of the health care workers?  
Current staff are asked to work regular hours (40 hours a week), are asked to do the same jobs as before but have an increased patient load, increased meeting load all while the managers are being asked how they can come up with savings and that will include moving that very staff that is at the breaking point.
The department heads and managers are receiving information from the chain of command that refers to their work as being the problem using phrases as " limited accountability to others in the system, variable plans, lack of benchmarks, or even competing priorities.
The manager gets their budget for the year and it gives a factor to each staff member from .1 to 1.0. So that manager finds out that a staff manager has to work full time for each hour they work but as everyone is trying to find ways to reduce costs and hours they make so with less.
So the manager gets a report from some office that says nurse----- now has to work 80% of the time not 100%, that means the manager can pay 80% of their hours (32 hours).  The health care worker is still paid 40 hours 100% (but the difference of 8 hours is that there is the same patient load and the same effort, the same number of meetings the same issues that their work involves).  The Alberta Health care budget may have saved on two fronts no overtime, no add on staff but the worker has to work 32 hours under one department.  They then go to another department with all their patients needs as before, same meetings, same personnel issues work there for 8 hours with their 100% patient needs.  

If it sounds confusing, it is.
Imagine you have a staff of 8 and yet they all work at .8, you have the mental health people on board and they can only provide .1 of their efforts to you even if you have more of a need or less of a need), then you may have a rehab need of .6 but yet you are now only allotted .1 staff time for them to do their job.  You have successfully completed your job as a manager as you are under budget.  The rehab staff will do their job and will either under report their work to make sure the patients needs are covered or be innovative in work loads and health care given.
We construct buildings but forget that if you work the staff to death, expect them to do 1.2 (or 120% of the work) and only pay .8 (80%... 32 hours a week) then we will always have a health care problem in Alberta.. its not about money its how the money that we have flows through the system.
This is why the morale of the Alberta Health is at an all time low even though expenditures are up, new buildings are being built or are built and there is a future for a health care worker in Alberta.  It seems that in black and white in cold accounting terms that everyone should be happy and content.  
The expectation is that the government won't repeat the mistakes of the past.  If by simply moving budgets and using innovative accounting methodology that businesses across the world use on an every day basis we can full fill the health care needs of every day Albertans.  
The focus of Alberta Health Care should be on the patient, the staff and the board in that order.
 Performance matrix, quantifiable measures, and other accounting tools that utilize cold facts without looking at lifespan outcomes (physical and mental health) is the problem.
The real question is where does the patient fit into this accounting system? 

From Dr David Duckett's Blog one can easily see that the problem of extended wait time in Alberta's Health Care is a combination of all Health care agencies in Alberta and not the problem of the board, their wages or the world economic situation...... (possibly referred to as other external factor)

He sees the Emergency Wait times problem mainly because the staff, the managers and departments are not doing the appropriate accounting (offensively worded as lack of benchmarks, variable care plans and even independent accountability to others in the system) and had they used the appropriate outcome measuring tools then we would not have Emergency room wait times that fall into second world categories.

"In this case, because every hospital and long-term care centre is different, 'performance' means achieving the goal of meeting the unique needs of patients.  This will require us to identify quality metrics, performance against which will attract additional funding to support greater patient needs. Quantifiable measures of health system performance are complex to develop, but not impossible.  All this is not rocket science, as they say.  Developing performance metrics for organizations or systems builds on what we do everyday when we plan a project with our colleagues or team.  We sit down and talk about what we want, what's achievable, what will change and make things better for our patients, and we evaluate our progress.  Thinking again about getting down those mountains quickly, there are lots of ways to get to the same end point.  People can be very innovative in how they get there and we at Alberta Health Services should nurture and encourage that same creativity and pursuit of innovation as we work toward our goals."  
 Performance matrix's and Dr David Duckett's desire to implement those within AHC from his blog.
I will tell a quick story about when I was being fitted with a prosthetic devices after my injury in Afghanistan.  Everyday for two months I would attend physio two times a day and for a full moth i tried and learned to stand.  The patient opposite of me encouraged me every day to do the right thing.  I learned off her and with my encouragement she saw that she could do it as i saw in her eyes to do the same and relearn to walk again after losing her leg below the elbow.   

Now the story on the surface is a true success story but as always there is more to this success of two patients using peer support and helping each other than what you see.

But when we add that I have the best insurance policy in Canada, as a 40 year old soldier (Department of Defence) and she a 90 year old great grandmother she was not in the most enviable position.  According to performance matrix, outcome measures she should have been placed in an old folks home and the scarce resources of Alberta Health care should have been used on a patient that had a greater chance of success.
  The team at the Glenrose Rehabilitation Hospital treated her with dignity, respect, with skill, humanity and she will able to hold her head high as she lives her life.  She also walked out of that hospital.  She is alive today and is living a proud, happy, healthy life as  a 93 year old amputee.  
Performance matrix's don't enter that story its a story about doing the right thing.
What would have happened if we considered her age as a factor in saving money?
There are no unique needs of patients.

"I want more life, fucker."
Roy Batty (Rutger Hauer) in  Blade Runner just before he kills his maker  Eldon Tyrell

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